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Need to know: Paediatrics

Consultant paediatrician Dr Andrew Boon answers questions on child health dilemmas from GP Dr Peter Randall

1. Is there any evidence for probiotics in treating toddler diarrhoea?

Probiotics have been shown to be of benefit in children with infective diarrhoea. Lactobacillus rhamnosus has been shown to reduce the duration of infective diarrhoea in infancy, particularly that caused by rotavirus infection, by about 50 per cent. It has also been used in the prophylaxis of diarrhoea in malnourished children.

Bifidobacterium bifidum has been shown to reduce the incidence of rotavirus diarrhoea. However, as far as I am aware, there is no evidence that probiotics have any effect in treating toddler diarrhoea.

Toddler diarrhoea usually occurs between the age of six months and two years and usually resolves spontaneously by the third year. Children with toddler diarrhoea show a normal rate of growth and weight gain.

Generally all that is required is to reassure parents that this is a harmless self-limiting condition. Dietary modification may produce an improvement in the diarrhoea – increasing the fat intake slows transit time, and reducing the amount of fruit juice and modifying the fibre intake may also produce an improvement.

2. Cow's milk protein intolerance seems to be much less popular as a diagnosis now, with a much reduced use of soya-based milks in practice. Is this diagnosis currently less fashionable among health visitors?

I agree that there does appear to be a trend for a reduction in health visitor-diagnosed cow's milk protein intolerance. One reason is that there is a reduction in serious cases of gastroenteritis with resultant decrease in the incidence of post-enteritis enteropathy, almost certainly due to better management of infective gastroenteritis in primary care.

Second, I suspect there was previously a lower threshold for diagnosing cow's milk intolerance. The recommendation made by the Chief Medical Officer not to use soya-based formulas in infancy because of their phyto-oestrogen content meant that only cow's milk hydrolysates could be used for treating cow's milk protein intolerance. This implies there has to be doctor involvement to prescribe the hypo-allergenic formula.

3. Is male adolescent mastitis ever serious?

It depends what is meant by adolescent mastitis. If we are talking about gynaecomastia of puberty, this occurs in up to two-thirds of boys. Usually this takes the form of a small nodule of breast tissue which may be quite painful or tender. Almost invariably this will resolve spontaneously.

Occasionally, particularly in overweight boys, the degree of gynaecomastia may be sufficient to cause severe psychological problems for which breast reduction surgery is indicated. It is very uncommon for there to be any underlying endocrine disorder causing the gynaecomastia. But if lactation occurs as well this should raise the possibility of a prolactinoma.

4. The new vaccination schedule proposed for two, three and four months will now be different at each stage. This will create confusion for patients and potentially nurses. Is there really a rationale for making each of those three injections different?

Yes. In the previous schedule diphtheria, acellular pertussis, tetanus, polio and Hib were given at two, three and four months into one leg, and the meningococcal C vaccine into the other leg. There is now a considerable weight of evidence that it is only necessary to give two meningococcal C vaccines within the first three months.

For that reason the Department of Health has dropped the first of the meningococcal C vaccines. The other major change in the vaccine schedule is the introduction of the pneumococcal vaccine.

The department has therefore decided to make two changes at the same time. The new schedule will consist of diphtheria, acellular pertussis, tetanus, polio and Hib into one leg and the pneumococcal vaccine into the other leg at two months. At three months the five-in-one (DTaP, polio and Hib) will be given into one leg and meningococcal C into the other. At four months the baby will be given the five-in-one vaccine as one injection, with two further separate injections of the meningococcal C and pneumococcal vaccine. The two injections given into one leg should not be less than 2.5cm apart.

5. Are there false positives for the newborn hearing screening test?

The newborn hearing screening test consists initially of an otoacoustic emission test which depends upon the cochlea generating a sound in response to a click. If a baby fails this part of the test, this is followed by auditory brainstem response (ABR) effectively looking at the EEG response to a click.

The two tests taken together are extremely accurate and false positives rarely, if ever, occur. Having said that, the newborn hearing screening test will not detect babies with progressive hearing loss, either as a result of a conductive hearing loss or a progressive sensorineural hearing loss. It is therefore still very important to take notice of any parent who says they are concerned about their child's hearing, even if the child passed the newborn hearing screening test.

6. Do you feel the child health surveillance programme is adequate for the detection of visual defects? I have noticed an increasing number of children presenting with visual problems beyond the ideal age at which they should have been addressed.

There has recently been a significant change in the child health surveillance programme. The pre-school three-and-a-half-years check has been dropped, and replaced with a four-and-a-half-year check. Both the pre-school and four-and-a-half-year check detect problems that had not been noted by parents.

Major concerns with vision such as squint would usually have been reported to a GP or health visitor long before age three-and-a-half. The main visual problem detected at the four-and-a-half check is anisometropia (unequal visual acuity in the two eyes). Detection of this is much more accurate at four-and-a-half than pre-school age so treatment can be more effectively targeted.

The current child health surveillance programme is entirely satisfactory for the detection of visual defects, and there is no evidence that this has had a detrimental effect with increasing visual problems in children.

7. Is there any evidence that applying the inside of a banana skin to children's plantar warts actually works?

Surprisingly there is a case report published in 1981 describing treatment of plantar warts with banana skin. However, a Cochrane systematic review concluded that the best available evidence was for simple topical treatments containing salicylic acid which are clearly better than placebo.

Interestingly the average cure rate of placebo preparations was 30 per cent, with a range of 0 to 73 per cent after an average period of 10 weeks. There is less evidence for the efficacy of cryotherapy, which showed no difference from placebo. Another trial that compared cryotherapy with duct tape again found no real difference in efficacy.

8. Is Tourette's syndrome on the increase, or is this due to an increased awareness of the diagnosis – or possibly a convenient label for antisocial behaviour?

There is no good evidence that the incidence of Tourette's syndrome is increasing.

Simple motor tics are extremely common and occur at some time during the late pre-school and early school years in at least 10 per cent of all children. Full-blown Tourette's syndrome is relatively rare. However, quoted prevalence rates vary widely between one and 10 per 1,000 children.

There is increased public awareness of this disorder as a result of media attention, which may have resulted in increased awareness of the diagnosis. There is certainly no evidence that this is being used as a convenient label for antisocial behaviour – however, there is a significant co-morbidity between Tourette's syndrome and ADHD.

9. How should I advise on nightmares?

Nightmares are a form of parasomnia, which is a disturbance of the normal transition from one sleep state to another. They manifest as nightmares, sleepwalking, sleep talking and night terrors.

Generally all that is required is reassurance for the parents. They usually occur an hour-and-a-half to two hours after the child has gone to sleep. There is evidence that by waking the child shortly before the parasomnia is due to occur this may break the cycle by resetting the sleep pattern.

They often run in families and generally are not an indication of any major underlying psychological problems. Drug treatment is best avoided for this condition.

10. Is the new appliance for treating bat ears in the neonatal period effective?

Congenital ear deformities are very common and traditionally have been treated by otoplasty. Splintage, if started in the neonatal period, is very effective and there are a number of studies in peer-reviewed journals which confirm this.

The device used most commonly in this country is 'Ear Buddies'. Deformities can be treated very effectively without the need for surgery or anaesthetic and with minimal cost. There is a narrow window of opportunity to use these devices and therefore treatment should be undertaken as early as possible in the neonatal period.

Correction of the deformity usually takes between four and seven weeks.

11. Although sodium cromoglicate is still in the BTS and SIGN guidelines on asthma management, in practice it seems barely used. Has the pendulum swung far too much against the use of this very safe remedy?

The main reason why sodium cromoglicate is no longer used in asthma is that it has very little effect. The main age group in which it was used was in pre-school children whose parents were steroid phobic. There have been a number of excellent papers which have shown that when compared with inhaled steroids, cromoglicate has little more effect than placebo. Inhaled steroids in appropriate dosage are also very safe and have excellent anti-inflammatory actions.

Another important reason why cromoglicate has gone out of favour is that it has a bitter taste and is irritating to the upper airway.

12. When, if at all, should birthmarks be referred for consideration of laser therapy?

Capillary haemangiomas (port-wine stains) respond very well to laser therapy, particularly early in childhood. My recommendation would be to refer any child with an unsightly capillary haemangioma for possible laser therapy during the first year of life.

The results of treating strawberry naevi with laser therapy are probably worse than allowing nature to take its course.

Steroid therapy may be required for a strawberry naevus, particularly if it is in the

orbital region and interfering with the visual field.

If in doubt, a vascular naevus should be referred as laser therapy is much simpler and more effective early in childhood, with a reduction in psychological effects.

Andrew Boon is a general consultant paediatrician and director of women's and children's services at Royal Berkshire Hospital –

he is the convenor of the British Association of General Paediatrics, an examiner for the Royal College of Paediatrics and Child Health, and a vice-chair of the Part 2 MRCPCH board

Competing interests None declared

What I will do now

Dr Peter Randall responds to the answers to his questions

• It is good to hear an endorsement for the use of probiotics in children with infective diarrhoea and as a protection against problems arising from the use of antibiotics.

• Asking about lactation in male adolescents' physiological gynaecomastia is a useful tip.

• There seems to be accumulating evidence for the merits of waking your children before you go to bed yourself. It seems it not only controls nightmares but we know it helps with nocturnal enuresis.

• Early consideration of laser therapy for port-wine stains should obviate much unnecessary suffering for young children.

Peter Randall is a GP in Sandown on the

Isle of Wight

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